Female Patient History Form
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1 UC Health Center for Reproductive Health Female Patient History Form UC Health Physicians Office South 7675 Wellness Way, Suite 315 West Chester, Ohio The Christ Hospital 2123 Auburn Avenue, Suite A43 Cincinnati, Ohio P: (513) IDENTIFYING INFORMATION Name DOB / / Age Significant Other Name DOB / / Age Primary Language spoken:! English! Spanish! Other: Date this form completed / / Referred by: Primary Ob/Gyn Address Primary Care MD Address How long have you been attempting conception? Number of years married/together Reasons you are coming to see us: What questions do you want answered at this visit? 2. PREGNANCY HISTORY Total number of ALL pregnancies Full term births Premature births (less than 37 weeks) Miscarriages (less than 20 weeks) Elective abortions Ectopic/Tubal Pregnancies Adopted children Elective Months Infertility Weight Is current partner Date Miscarriage? Abortion? Ectopic? to conceive? Treatment? and sex? C-section? Complications? the father? 1. : : : : : : : : : 2. : : : : : : : : : 3. : : : : : : : : : 4. : : : : : : : : : 5. : : : : : : : : : 3. CONTRACEPTIVE USE Type From when to when Reason discontinued 1. : : 2. : : Revised February 1, 2010 Page 1 of 5
2 4. SURGERIES AND HOSPITALIZATIONS Date Reason and type of surgery Where Physician 1. : : : 2. : : : 3. : : : 4. : : : 5. MEDICAL HISTORY Do you have or have you had?! Cancer! Asthma! Kidney disorder! Psychiatric disorder! Diabetes! Pneumonia! Rubella! Seizures! Hypertension! Bronchitis! Anesthetic complication! Stroke! High cholesterol! Tuberculosis! Mumps! Blood clots! Heart disease! Hepatitis / liver disorder! Chicken pox! Anemia! Rheumatic fever! Gall bladder problems! Mononucleosis! Bleeding disorder! Scarlet fever! Ulcers! Serious injury / accident! Thyroid disorder! Mitral valve prolapse! Colitis / enteritis! Blood transfusion! Recent immunization! Heart murmur Any medical problem not listed above (please list type, dates, treatments) List all prescriptions and over-the-counter drugs used during the past year Date Dose and frequency From when to when Reason 1. : : : 2. : : : 3. : : : 4. : : : 6. ALLERGIES Drug or substance 1. : 2. : 7. MENSTRUAL/HORMONAL Reaction Menstrual cycle pattern (check all that apply):! Regular periods! Irregular periods! Spotting before periods! No periods! Heavy periods! Light periods! Bleeding between periods Age at first period... First day of last two menstrual periods / / and / / How many days from start of one period to start of the next period?... Pelvic pain/cramps:! none! during period! before period! after period! at mid cycle How many days of bleeding do you have?...days! during intercourse! with bowel movements! with urination! cause you to miss work! cause you to miss usual activities Pelvic pain/cramps are:! mild! moderate! severe! worsening! improving! no change! in midline! on right side! on left side Do you have or have you had? (Check all that apply)! Hot flashes! Increased facial or body hair! Breast discharge! Increased acne Please explain a Yes answer: Page 2 of 5
3 8. GYNECOLOGIC / INFECTION Last pap smear / / Do you have or have you had? Last mammogram / /! Pelvic infection! Appendicitis! Gonorrhea! Ovarian cysts! Chlamydia! Colitis or enteritis! Syphilis! Hepatitis! Endometriosis! Uterine fibroids or myomas! Mycoplasma! Cytomegalovirus (CMV)! Pelvic adhesions! Abnormal shape of uterus! Ureaplasma! HIV/AIDS! Cervicitis! Recurrent vaginitis! Genital warts / condyloma! Trichomonas! Genital herpes! Abnormal Pap smears! Cryo (freezing) or surgery! Other of the cervix 9. SEXUAL HISTORY Are you sexually active?! Yes! No Is your partner! Male! Female How many times do you have intercourse per week? Have you used over the counter ovulation kits to time intercourse?! Yes! No Do you have pain with intercourse?! Yes! No Do you use lubricants during intercourse?! Yes what types?! No 10. OTHER HISTORY Your occupation:... Alcohol - type and number per week:... Cigarettes How many per day?... How many years?... Quit When?... Marijuana - amount:... Other drugs - type and amount: Caffeinated beverages (coffee, tea, soda) per day:... Ever used intravenous drugs?! yes! no Radiation exposure:! yes! no 11. SYSTEMIC REVIEW Height Weight Maximum Weight Minimum Weight Weight change in last 2 yrs Do/have you participated in any significant dietary changes over the past 3 years?... Do/have you participated in any exercise programs over the past 3 years?... If so please document exercise: type... hrs/week...! The effect of being overweight on fertility therapies have been well documented.! Please speak with your physician regarding weight loss attempts and ideal weight range for you height.! Obesity does not usually cause infertility but it may have significant impact on treatment responses & may have multiple negative effects on both you & the fetus Check all that applies: General Musculoskeletal Breasts Respiratory! Recent weight gain / loss! Muscle weakness! Discharge (clear? bloody? milky? )! Shortness of breath! Anorexia/bulimia! Decreased energy/stamina! Lumps! Pain! Asthma! Bronchitis! Lack of energy! Rheumatoid arthritis! Cancer! Rash! Pneumonia! Asthma! Fever/Chills! Lupus erythematosus! Abnormal mammogram! Bloody cough! Other! Other! Reduction! Augmentation/implants! Other! Other Mental Health Problems Neurological Problems Endocrine/Hormonal! Depression! Anxiety Genito-Urinary! Weakness/loss of balance! Diabetes! Schizophrenia! Bladder infections! Seizures/Epilepsy! Hair loss! Other! Kidney infections! Headaches! Thyroid gland problems! Vaginal infections! Migraine headaches! Excessive thirst or hunger Head, Eyes, Nose, & Throat! Frequent urination! Numbness! Temperature intolerance! Dizziness! Leaking urine! Memory loss Hot flashes or feeling cold! Headaches! Blood in the urine! Other! Other! Blurred vision! Other! Hearing loss/deafness Skin/Extremities Gastrointestinal! Loss of sense of smell Hematologic! Unexplained rash! Nausea/vomiting! Chronic nasal congestion! Blood clotting disorder/blood clot! Acne! Ulcers! Other! Sickle cell anemia! Skin cancer! Diarrhea! Easy bruising! Excess hair growth! Constipation Cardiovascular! Swollen glands/lymph nodes! Moles changing appearance! Irritable Bowel Syndrome! Palpitations! Murmurs! Blood transfusions (dates/reasons )! Other! Change in bowel habits! Chest pain! Stroke! Other! Other! Heart attack! Mitral valve prolapse! Other Page 3 of 5
4 12. FAMILY HISTORY / GENETIC HISTORY Cancer (type) Diabetes Hypertension High Cholesterol Heart Disease Stroke Uterine fibroids Endometriosis Menopause before age 40 Mother Father Brothers: # Sisters: # Children: # Other 13. ETHNICITY *Data will be used for genetic testing recommendation purposes! Caucasian! Hispanic! Asian! African American! Other ( ) Do you or anyone in either family have?! Neural tube defects/spina! Cystic fibrosis! Tay-Sachs disease! Chromosomal disorder bifida/anencephaly! Muscular dystrophy! Sickle cell disease or trait! Genetic / inherited disorder! Thalassemia! Huntington chorea! Hemophilia! Baby with birth defects! Down syndrome! Mental retardation / fragilex! Hormonal disorder! Infertility!Hydrocephalus!Epilepsy or seizures!kidney disease!mental illness!stillbirth!phenylketonuria!neurofibromatosis!myotonic dystrophy!3 or more miscarriages!diabetes! Any birth defects?! Any inherited disorders? Please explain a Yes answer to any of the above Genetic Screening: It is recommended that all couples attempting conception be offered cystic fibrosis screening. Cystic Fibrosis is a pulmonary disease affecting children and the most common genetic disease. The effectiveness of the test varies dependent on your ethnic background. You may be offered additional screening based on your ethnicity. Are you: African-American! Yes! No Ashkenazi Jewish! Yes! No Mediterranean/Asian/French Canadian! Yes! No If you answered YES to any of these, please let your physician know at the visit, so that the additional genetic screening can be offered to you. If you have any specific genetic concerns and desire to see a geneticist, please let the physician know. 14. HISTORY OF FERTILITY THERAPY (Fill out if applicable) Have you been treated for infertility previously?! YES! NO If yes, who was your physician?.. What cause of infertility was diagnosed? What drugs have you taken for infertility? Please check all that apply:! Clomid (Serophene)! hcg Profasi! Antibiotics! Gonal F! Progesterone! Baby aspirin! Follistim! Lupron! Heparin! Repronex! Microdose Lupron! Steroids! Pergonal! Antagon! Oral Contraceptives! Fertinex! Parlodel! Other... Page 4 of 5
5 Which of the following tests have you or your partner had performed? Please check all that apply and results, if known:! Hysterosalpingogram When / / Results....! Sonohystogram When / / Results....! Laparoscopy, Hysteroscopy When / / Results....! Thyroid tests When / / Results....! Chromosomes When / / Results....! Genetic screening When / / Results....! OTHER Have you ever undergone Artificial Insemination (IUI) or In Vitro Fertilization (IVF)?! YES! NO If yes,! partner! donor sperm #IUI s #IVF cycles At the UC Center for Reproductive Health, we understand that infertility can place a significant burden on the respective couple. This stress can have a profound impact on the reproductive system. Given these facts and our emphasis on treating the whole person, we would like to know your experience with / willingness to try alternative therapies. These include, but are not limited to:! Acupuncture ( if so, which acupuncturist)! Herbal treatment! Massage! Psychological/group therapy! Yoga / biofeedback / stress reduction techniques PATIENT S SIGNATURE DATE I confirm that I have reviewed the above information. PHYSICIAN S SIGNATURE DATE Welcome and we look forward to working with you. Please write down any specific concerns you want to review at your visit. Thank you - The UC Center for Reproductive Health Team Page 5 of 5
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Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Difficulty Conceiving? Yes No. Yes No. Yes No. Yes No
FEMALE INFORMATION Name: _ Birth date: _ Total Number of Pregnancies: Occupation: Married Single Term births: Race: Height: ft inches Pre-term births: Religious Affiliation: Weight: pounds Miscarriages/Abortions:
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Welcome to Providence Medical Group-OB/GYN Health Center. Dear Patient,
Providence Medical Group OB-GYN HEALTH CENTER 940 Royal Ave., Suite 350 Medford, OR 97504 Tel: 541-732-7460 Fax: 541-732-7461 Providence Medical Group OB-GYN (CENTRAL POINT LOCATION) 870 S. Front St.,
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
New Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any
MEDICAL QUESTIONNAIRE
Center for Restorative Pelvic Medicine MEDICAL QUESTIONNAIRE Dear Patient: Please take a few minutes to complete this form. This will help assure you of the best possible care and will be held in confidence
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital